Provider Demographics
NPI:1801143813
Name:ELLIS, TIMOTHY RAY (DDS)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:RAY
Last Name:ELLIS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11836 ELM ST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68144-4438
Mailing Address - Country:US
Mailing Address - Phone:402-334-8208
Mailing Address - Fax:402-334-1106
Practice Address - Street 1:11836 ELM ST
Practice Address - Street 2:SUITE 1
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68144-4438
Practice Address - Country:US
Practice Address - Phone:402-334-8208
Practice Address - Fax:402-334-1106
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-08
Last Update Date:2012-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE45361223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice